Provider Demographics
NPI:1548515521
Name:WARD, JUSTIN ALAN (DPM)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALAN
Last Name:WARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 PAN AMERICAN FWY NE STE 234
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6834
Mailing Address - Country:US
Mailing Address - Phone:505-880-1000
Mailing Address - Fax:505-880-1002
Practice Address - Street 1:4343 PAN AMERICAN FWY NE STE 234
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107
Practice Address - Country:US
Practice Address - Phone:505-880-1000
Practice Address - Fax:505-880-1002
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT1240213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28855035Medicaid